Out With The Old

Experts call for change with obsolete tobacco control efforts.

By Amber Whaley

It doesn’t take a scientist to see that the world of “smoking” has changed drastically over the past decade. With the invention and innovation of the electronic cigarette, people have been looking at nicotine in a completely different way. And while e-cigarettes do not contain tobacco, they are considered by many, the U.S. Food and Drug Administration (FDA) included, as a new tobacco product. If that is the case, then we have to admit that since 2007, when the first e-cigarette was introduced, the “tobacco” market has changed.

A recent paper published in the journal BMC Public Health is exploring this fact and at the same time encouraging the modernization of how we design and implement tobacco control strategies.

Lynn Kozlowski is a professor of community health and health behavior at the University at Buffalo. He co-authored the paper with David Abrams, a professor of health, behavior and society at Johns Hopkins University. Abrams is also the director of the Schroeder Institute for Tobacco Research and Policy Studies at Truth Initiative in Washington, D.C. The two authors believe that the major issue is the lack of adaptation to the changing tobacco product landscape.

The researchers analyze the history of tobacco control and how it has changed, or in some cases has not changed, over the course of organized tobacco control. Beginning in 1964 with the surgeon general’s warning on cigarettes and tobacco products, U.S. efforts toward tobacco control have had an inconsistent history. For instance, beginning in 1964 there was a large trend toward the newly introduced “light” cigarette, which was touted by public health officials at the time as having less tar—and therefore providing a lower risk of contracting lung cancer. Time would tell, however, that this was not the case.

While light cigarettes did not prove to be the harm reducers many were hoping for, they should not have erased the idea of harm reducers in general. However, according to the researchers, by the 1980s the popular thought was more aligned to an “all or nothing” approach—smoking was seen as bad and no alternative product should ever be considered acceptable for use.

Also in the 1980s, broader bans on cigarette advertising were introduced and the overall feel of tobacco control turned. No longer were people trying to make claims about harm reduction with lower-tar cigarettes or alternative smoking methods; smoking was just bad. The failure of the low-tar harm reduction fiasco is that it has affected the feel of tobacco control now, even years later. The authors say it is time for a change. “Tobacco control needs to be guided by a modern understanding of differential risks from different modes of delivery of tobacco/nicotine containing products in the practice of tobacco control, not crude, unjustified claims of product risks based on the fraudulent industry behavior of the light/low tar disaster,” they write.

Indeed, the authors’ main point rests around the sense that something different needs to be done. No longer should e-cigarettes, snus and other different methods of nicotine delivery be lumped together with other combustible tobacco products. Abrams and Kozlowski propose redefining the ideas that now preside over tobacco control strategies in our country. “A new reframing can align action plans to more powerfully and rapidly achieve population-level benefit and minimize harm to eliminate in our lifetime the use of the most deadly combustible tobacco products and thus prevent the premature deaths of 1 billion people projected to occur worldwide by 2100.”

In turn, once the framework is changed, policymakers need to take notice. “Regulators and policymakers must keep the big picture in mind when framing key messages to accurately inform consumers.”

Since the tobacco product landscape has grown and changed so rapidly, it is hard for researchers and policymakers both to stay caught up. E-cigarettes, as well as other noncombustible tobacco alternatives, have quickly become popular among former smokers who are seeking different ways to administer nicotine without the harmful cigarette smoke. Several health organizations, such as the Royal College of Physicians and Public Health England, have backed e-cigarettes as harm reducers, reporting that they are as much as 95 percent less harmful than regular cigarettes. Compared with traditional cigarettes, which kill over 400,000 people a year, e-cigarettes can offer a pathway to nicotine use that excludes the harmful smoke and tar.

That is why the authors are so reluctant to allow e-cigarettes to continue to be grouped with combustible tobacco products. Kozlowski and Abrams state that e-cigarettes and other alternative nicotine-delivery systems “have substantially lower harms than cigarettes. Going forward, it is important to sharpen themes and key messages of tobacco control, while continuing to emphasize the extreme lethality of the inhaled smoke from cigarettes or from use of any combusting tobacco product.”

The changing landscape needs to be acknowledged, especially for regulators who are now making drastic decisions based on an antiquated system. Kozlowski believes that regulation needs to be addressed in order to reflect this changing landscape and unique opportunity that e-cigarettes can represent. “Regulation should be used to strike the balance so urgently needed between protecting nonusers, especially youth, while maximizing benefits of newly regulated noncombustible e-cigarette products that have been shown to help current smokers either to switch or, ideally, to quit.”

The report is an important commentary, coming from American experts just when e-cigarettes are facing so many regulation challenges. The authors bring to light the important first step in the acceptance of vaping, and that is to recognize just how differently we have to view the tobacco product landscape in general. Kozlowski puts it into perspective: “Not since the invention of the cigarette-rolling machine in 1882 has the product landscape changed so dramatically. For the first time in over a century, there are products that could make the defective and deadly cigarette obsolete.”